Embolization of peripheral high-flow arteriovenous malformations with Onyx

Vascular embolic nanobiomaterials for efficient tumor treatment

Embolization is a minimally invasive cancer treatment method. Embolization involves artificially blocking blood flow using an embolic agent to block abnormal blood vessels that supply nutrients or oxygen to a specific lesion, thereby killing the lesion, inhibiting its growth, and stopping bleeding. Currently, polyvinyl alcohol (PVA) and gelatin are the most popular embolic agents. These substances are available in various sizes and shapes that physically obstruct blood flow to cause vascular embolization. They are commonly used due to their ease of use and low cost. However, they can cause side-effect such as bleeding and potential complications related to catheter- and insertion-related complications. Recently, nanobiomaterials have been explored as embolization agents with high biocompatibility, such as liquid metals, and can be used with autologous blood. In this review, we cover the types of embolic agents currently used in cancer treatment and focus on those with fewer adverse effects and minimal vascular damage, followed by discussions on new embolic agents under development. Additionally, we explore potential future research directions for developing better embolic agents.

Diagnosis and management of superficial arteriovenous malformations: French healthcare network's recommendations

Superficial arteriovenous malformations are rare fast-flow lesions. They consist of arteriovenous shunts, without cellular hyperplasia or proliferation, which develop in the surrounding tissues (cutaneous, subcutaneous, muscular, bone). Although benign, they are among the most severe of superficial malformations. Their evolution can be life-threatening in exceptional cases. With the aim of optimizing diagnosis and management worldwide, this  protocol offers a state of the art for the diagnosis and management of these diseases. To this end, the French healthcare network specialized in these diseases have drawn on literature data and experience. Developed from the French National Diagnosis and Care Protocol, it presents the patient journeys for initial and differential diagnoses, and personalized therapeutic strategies. This requires a multidisciplinary team, with specialized professionals in handling genetic, treatment and psychosocial issues.

Extracranial arteriovenous malformations: a 10-year experience at a German vascular anomaly center and evaluation of diagnostic imaging for endovascular therapy assessment

Background

Arteriovenous malformations (AVMs) account for <3% of vascular anomalies. This study aims to present the 10-year experience of a German vascular anomaly center (VAC) with AVMs and evaluate diagnostic imaging for treatment-relevant information for minimally invasive therapy planning.

Material and methods

A retrospective study including patients from the VAC database with AVMs was conducted. Clinical information from patients' records was evaluated. An additional image reading analysis of the available diagnostic imaging using a 4-point Likert scale, focusing on relevant points for minimally invasive treatment planning, was conducted in 13 patients who had all three magnetic resonance tomography (MRI), computed tomography (CT), and conventional angiography available.

Results

Between April 2014 and March 2024, 60 patients (60% female, 40% male; 12% Parkes Weber syndrome) with AVMs presented to the VAC. The median age was 36 years (range: 11-78 years). Referral diagnosis was correct in 73.3% of cases. The mean distance to the VAC was 102.5 km (±111.0). The most common locations involved the hand (32%), lower extremity (22%), and pelvis (22%). The most common symptoms were pain (81%), pulsation (64%), and local hyperthermia (62%). Necrosis was significantly more common when the AVM was located in the hand (p = 0.0129) and growth when located in the pelvis (p = 0.0037). Furthermore, cosmetic issues were significantly more frequent when the AVM was located in the head area (p = 0.0333). Most patients presented with Schobinger stage II (57%). Right heart strain was only documented in one case. A total of 47% had undergone invasive therapies before VAC admission. In 30% of cases, further minimally invasive or invasive therapy was required. In the diagnostic imaging evaluation, conventional angiography had the overall best ratings for image quality (median = 1.00; range: 1.00-2.00), NIDUS evaluation median = 1.00; range: 1.00-2.00), and therapy planning (median = 1.00; range: 1.00-1.33).

Conclusion

Our 10-year experience showed that in patients with AVMs, the correct diagnosis is often made before admission to a specialized VAC. Diagnostic imaging is essential for endovascular treatment planning, with conventional angiography showing superior utility in image quality, NIDUS evaluation, and therapy planning compared to other modalities.

Staged endovascular and open surgical approach for treatment of a giant left upper back arteriovenous malformation

We present a case of a symptomatic, giant, left upper back arteriovenous malformation that was treated through a staged endovascular and open approach. Through a series of embolizations, followed by resection, we were able to preserve the limb and upper back neurovascular supply, demonstrating an approach to preserve sensation and function and improving quality of life.

Successful embolization of an anterior chest wall arteriovenous malformation using combined transfemoral and transradial approaches with onyx

We present a case of successful embolization of an anterior chest wall arteriovenous malformation (AVM) in a 24-year-old male patient. This report aims to highlight the efficacy and safety of using the liquid embolic agent (onyx) as well as the combined approaches (trans-femoral and trans-radial) in managing rare complex chest wall AVMs.

Peripheral Arteriovenous Malformation Embolization Using Squid

Materials and Methods

Between January 2018 and December 2020, twenty patients (7 men and 13 women) with peripheral high-flow arteriovenous malformations who were treated primarily with arterial embolization using squid were retrospectively included. Anatomical sites being treated included the head and neck (16), extremities (2), uterus (1), and pelvis (1). Squid was used as the sole embolic agent in 15 patients, and transarterial embolization was employed in all cases except one where direct puncture embolization was used. Treatments were delivered over one or two sessions, with or without surgery. A total of 27 sessions were carried out with an interval time ranging from 6 to 36 months between sessions.

Results

Technical success was achieved in all cases. In those patients treated with squid alone, 13 exhibited total devascularization following embolization, and a further 4 required surgical excision to achieve complete obliteration of the arteriovenous malformation. There were no major complications, cases of microcatheter entrapment, or dimethyl sulfoxide-related pain recorded. On follow-up, one patient reported persistent pain, and another patient developed a garlicky taste. All other patients reported complete resolution of symptoms following treatment.

Conclusion

This study demonstrates the successful use of squid in managing peripheral arteriovenous malformations with low complication rates and long-term stable results, therefore validating its efficacy when used alone or in combination with other embolic agents. Squid may be the preferred embolic agent in any interventional radiologist's armamentarium as it offers formulations with varying viscosities (squid-18 and squid-12). We conclude that squid should be considered as a first-line embolic agent in the management of peripheral arteriovenous malformations.

Liquid Embolic Agents for Endovascular Embolization: A Review

Endovascular embolization (EE) has been used for the treatment of blood vessel abnormalities, including aneurysms, AVMs, tumors, etc. The aim of this process is to occlude the affected vessel using biocompatible embolic agents. Two types of embolic agents, solid and liquid, are used for endovascular embolization. Liquid embolic agents are usually injectable and delivered into the vascular malformation sites using a catheter guided by X-ray imaging (i.e., angiography). After injection, the liquid embolic agent transforms into a solid implant in situ based on a variety of mechanisms, including polymerization, precipitation, and cross-linking, through ionic or thermal process. Until now, several polymers have been designed successfully for the development of liquid embolic agents. Both natural and synthetic polymers have been used for this purpose. In this review, we discuss embolization procedures with liquid embolic agents in different clinical applications, as well as in pre-clinical research studies.

Recent progress in liquid embolic agents

Vascular embolization is a non-surgical procedure used to treat diseases or morbid conditions related to blood vessels, such as bleeding, arteriovenous malformation, aneurysm, and hypervascular tumors, through the intentional occlusion of blood vessels. Among various types of embolic agents that have been applied, liquid embolic agents are gaining an increasing amount of attention owing to their advantages in distal infiltration into regions where solid embolic agents cannot reach, enabling more extensive embolization. Meanwhile, recent advances in biomaterials and technologies have also contributed to the development of novel liquid embolic agents that can resolve the challenges faced while using the existing embolic materials. In this review, we briefly summarize the clinically used embolic agents and their applications, and then present selected research results that overcome the limitations of the embolic agents in use. Through this review, we suggest the required properties of liquid embolic agents that ensure efficacy, which can replace the existing agents, providing directions for the future development in this field.

Liquid Embolization of Peripheral Arteriovenous Malformations with Ethylene-Vinyl Alcohol Copolymer in Neonates and Infants

In the postnatal period, extensive peripheral arteriovenous malformations (AVM) are associated with high morbidity, especially when localized in the liver. Their urgent treatment is always a challenging problem in neonates and infants. We analyzed four consecutive children aged three days to three years who underwent eight liquid embolization procedures with ethylene-vinyl alcohol copolymer. The AVM were situated on the thoracic wall, in the liver, and on the lower leg. In three cases, the malformations showed total regression. The tibial AVM degenerated widely. If impaired beforehand, cardiac or hepatic function normalized after the interventions. There were no embolization-associated complications such as nontarget embolization or tissue ischemia. We conclude that application of ethylene-vinyl alcohol copolymer seems to be a safe therapeutic option and can be used in neonates and infants with peripheral AVM in consideration of the agent's characteristics. Nevertheless, there are still hardly any data concerning young children.

Image-Guided Embolotherapy of Arteriovenous Malformations of the Face

PURPOSE

To evaluate the safety and outcome of image-guided embolotherapy of extracranial arteriovenous malformations (AVMs) primarily affecting the face.

MATERIALS AND METHODS

A multicenter cohort of 28 patients presenting with AVMs primarily affecting the face was retrospectively investigated. Fifty image-guided embolotherapies were performed, mostly using ethylene-vinyl alcohol copolymer-based embolic agents. Clinical and imaging findings were assessed to evaluate response during follow-up (symptom-free, partial relief of symptoms, no improvement, and progression despite embolization), lesion devascularization (total, 100%; substantial, 76-99%; partial, 51-75%; failure, < 50%; and progression), and complication rates (classified according to the CIRSE guidelines). Sub-analyses regarding clinical outcome (n = 24) were performed comparing patients with (n = 12) or without (n = 12) subsequent surgical resection after embolotherapy.

RESULTS

The median number of embolotherapy sessions was 2.0 (range, 1-4). Clinical outcome after a mean follow-up of 12.4 months (± 13.3; n = 24) revealed a therapy response in 21/24 patients (87.5%). Imaging showed total devascularization in 14/24 patients (58.3%), including the 12 patients with subsequent surgery and 2 additional patients with embolotherapy only. Substantial devascularization (76-99%) was assessed in 7/24 patients (29.2%), and partial devascularization (51-75%) in 3/24 patients (12.5%). Complications occurred during/after 12/50 procedures (24.0%), including 18.0% major complications. Patients with subsequent surgical resections were more often symptom-free at the last follow-up compared to the group having undergone embolotherapy only (p = 0.006).

CONCLUSION

Image-guided embolotherapy is safe and effective for treating extracranial AVMs of the face. Subsequent surgical resections after embolization may substantially improve patients' clinical outcome, emphasizing the need for multimodal therapeutic concepts.

LEVEL OF EVIDENCE

Level 4, Retrospective study.

Image-Guided Embolotherapy of Arteriovenous Malformations of the Face

Purpose

To evaluate the safety and outcome of image-guided embolotherapy of extracranial arteriovenous malformations (AVMs) primarily affecting the face.

Materials and Methods

A multicenter cohort of 28 patients presenting with AVMs primarily affecting the face was retrospectively investigated. Fifty image-guided embolotherapies were performed, mostly using ethylene–vinyl alcohol copolymer-based embolic agents. Clinical and imaging findings were assessed to evaluate response during follow-up (symptom-free, partial relief of symptoms, no improvement, and progression despite embolization), lesion devascularization (total, 100%; substantial, 76–99%; partial, 51–75%; failure, < 50%; and progression), and complication rates (classified according to the CIRSE guidelines). Sub-analyses regarding clinical outcome (n = 24) were performed comparing patients with (n = 12) or without (n = 12) subsequent surgical resection after embolotherapy.

Results

The median number of embolotherapy sessions was 2.0 (range, 1–4). Clinical outcome after a mean follow-up of 12.4 months (± 13.3; n = 24) revealed a therapy response in 21/24 patients (87.5%). Imaging showed total devascularization in 14/24 patients (58.3%), including the 12 patients with subsequent surgery and 2 additional patients with embolotherapy only. Substantial devascularization (76–99%) was assessed in 7/24 patients (29.2%), and partial devascularization (51–75%) in 3/24 patients (12.5%). Complications occurred during/after 12/50 procedures (24.0%), including 18.0% major complications. Patients with subsequent surgical resections were more often symptom-free at the last follow-up compared to the group having undergone embolotherapy only (p = 0.006).

Conclusion

Image-guided embolotherapy is safe and effective for treating extracranial AVMs of the face. Subsequent surgical resections after embolization may substantially improve patients’ clinical outcome, emphasizing the need for multimodal therapeutic concepts.

Level of Evidence

Level 4, Retrospective study.

Interventional Treatment Options in Children with Extracranial Vascular Malformations

Extracranial vascular malformations vary greatly and belong to the complex field of orphan diseases and can involve all segments of the vascular tree: arteries, capillaries, and veins, and similarly the lymphatic system. The classification according to the International Society for the Study of Vascular Anomalies (ISSVA) represents an important guidance for selecting appropriate therapy. Although many of the principles of endovascular treatment, including image-guided sclerotherapy and embolization, are similar in adult and pediatric practice, there are some distinct differences regarding the treatment of vascular malformations of children. Thus, it is crucial to involve longer-term plan about managing these chronic diseases and their impact on a growing child. This review provides a detailed overview over the clinical presentation of venous, lymphatic, and arteriovenous malformations in children and emphasizes the specifics of their interventional treatment options, including distinct pediatric dose limitations and procedure-related side effects.

Evaluation of Multiple Embolic Agents for Embolization of the Superior Rectal Artery in an Animal Model

OBJECTIVE

To prospectively compare the safety of transcatheter embolization of superior rectal arteries in healthy pigs with multiple agents such as coils, spheres and liquids.

MATERIALS AND METHODS

Nine adult domestic pigs (three males, mean weight: 60 kg [50-70]) were randomly assigned to the embolization group: copolymer of ethylene vinyl alcohol (EVOH)-Onyx® (group 1, n = 3), microspheres 500 µ (group 2, n = 3), 2-mm micro-coils (group 3, n = 3). After a selective angiogram has been acquired, the embolic agent was infused at the distal part of rectal arteries. An angio-CT was performed before and after each embolization. After one week, angiography was repeated prior to euthanasia. At necropsy, the anorectal juncture was removed for histopathologic examination.

RESULTS

At necropsy, 100% of animals embolized with Onyx developed a significant necrosis zone of the distal part of the rectum. Histological examination revealed a mural infarction. For the micro-coil and microsphere groups, gross examination of the intestines did not reveal any evidence of ischaemia. The coils were found in the distal arterial vasculature of the meso-rectum, allowing a downstream revascularization by collaterals. The microspheres and onyx in the rectal wall, more distally.

CONCLUSION

Microspheres appear to induce fewer histologic complications than the liquid embolic agent and provide a more distal occlusion than micro-coils. These results suggest that, for superior rectal artery embolization, a super-selective embolization using spheres in human clinical conditions should be more effective and as safe as coil embolization. EVOH might be an unsafe embolization agent for haemorrhoids.

Non-Adhesive Liquid Embolic Agents in Extra-Cranial District: State of the Art and Review of the Literature

This review focuses on the use of “new” generation of non-adhesive liquid embolic agents (NALEA). In literature, non-adhesive liquid embolic agents have mainly been used in the cerebral district; however, multiple papers describing the use of NALEA in the extracranial district have been published recently and the aim of this review is to explore and analyze this field of application. There are a few NALEA liquids such as Onyx, Squid, and Phil currently available in the market, and they are used in the following applications: mainly arteriovenous malformations, endoleaks, visceral aneurysm or pseudoaneurysm, presurgical and hypervascular lesions embolization, and a niche of percutaneous approaches. These types of embolizing fluids can be used alone or in combination with other embolizing agents (such as coils or particles) so as to enhance its embolizing effect or improve its possible defects. The primary purpose of this paper is to evaluate the use of NALEAs, predominantly used alone, in elective embolization procedures. We did not attempt a meta-analysis due to the data heterogeneity, high number of case reports, and the lack of a consistent follow-up time period.

Venous malformations

The often inexorable growth and expansion of congenital vascular malformations can result in substantial morbidity and, in some cases, premature death of these patients. Despite this, patients suffering from such lesions are often erroneously diagnosed and/or inadequately treated, due to a lack of expertise among primary care practitioners as well as specialists. Venous malformations are the most common type of congenital vascular malformations. Over the last two decades management of these lesions has significantly improved, predominantly due to the introduction and implementation of multidisciplinary team concept as well as improvement in diagnostic and treatment modalities. Relatively recently genetic studies are providing more insights into underlying pathophysiological mechanisms responsible for the development and progression of venous malformations and pharmacotherapy is becoming extensively evaluated for safety and efficacy in the treatment of these often challenging vascular lesions.

The use of dual-lumen balloon for embolization of peripheral arteriovenous malformations

PURPOSE

We aimed to evaluate the safety and feasibility of the embolization of peripheral arteriovenous malformation (AVM) with non-adhesive liquid agents (NALA) injected by dual-lumen balloons (DLB).

METHODS

We conducted a multicenter retrospective study between January 2017 and June 2019, including patients with peripheral AVM embolized with NALA by DLB. Fourteen patients were included. The AVM classification, technical and clinical success were evaluated, as were nidus size, liquid agent used, volume and time of injection in DLB, complications, follow-up and need of surgical intervention.

RESULTS

The mean age of the patients was 37±22.5 years (range, 6-82 years). The mean nidus size was 5.2±2.4 cm (range, 3.0-12.0 cm). By Schobinger classification, 11 AVMs were classified in stage 3 and 3 AVMs were classified in stage 2. By Cho's classification, 2 AVMs were in stage II, 4 AVMs were in stage I, 4 AVMs were in stage IIIa and 4 AVMs were in stage IIIb. Onyx was used in 11 patients (78.6%), while Squid, PHIL, and both Onyx and Squid were used in one patient each (7.1%). Seven patients (50%) required one session of embolization, 4 patients (28.6%) required two, 2 patients (14.3%) required three and 1 patient (7.1%) required four sessions. Complete nidus exclusion was achieved in 11 patients (78.6%), optimal clinical response in 12 patients (85.7%). Four patients (28.6%) exhibited minor complications, all controlled. No major complications were seen. Four patients underwent surgical intervention (28.6%).

CONCLUSION

The embolization of peripheral AVM with NALA in DLB appears to be safe and feasible, achieving high rates of technical and clinical success.

Vascular anomalies: Classification and management

Vascular anomalies are broadly classified into two major categories: vascular tumors and vascular malformations. Most vascular anomalies are caused by sporadic mosaic gene mutations, and recent genetic studies have advanced our understanding of the molecular pathways involved in their pathogenesis. These findings have suggested new therapeutic approaches to vascular anomalies, focusing on their pathogenetic mechanism. This chapter seeks to integrate an improved molecular understanding within the updated classification system of the International Society for Study of Vascular Anomalies. We emphasize the genetic, radiologic, and interventional aspects of diagnosis and management in hopes of allowing improved multidisciplinary collaboration surrounding these complex and interesting anomalies.

Endovascular approach to arterial branches mimicking a type II endoleak after popliteal artery aneurysm exclusion and bypass

The management of popliteal artery aneurysms (PAAs) has continued to evolve. Open surgical treatment remains an excellent option. Aneurysm exclusion with saphenous vein bypass through a medial incision remains a preferred approach. After PAA exclusion, however, a possibility remains of sac expansion from geniculate arterial branches. This can mimic a type II endoleak occurring after endovascular aortic aneurysm repair. In the present report, we have described an endovascular technique used to treat an enlarging PAA after exclusion and bypass.

Treatment Outcomes of Embolization for Peripheral Arteriovenous Malformations

PURPOSE

To evaluate treatment outcomes of embolization for peripheral arteriovenous malformations (AVMs) in a tertiary referral center where ethanol is the primary agent of choice.

METHODS

A retrospective study was performed of 93 patients (median age, 31 years; range, 2-66 years) with peripheral AVMs treated with embolization (n = 442; median, 2 per patient; range, 1-82) between January 2010 and July 2016. Ethanol was used in most cases (n = 428; 97%). AVMs were classified as type I (n = 3), type II (n = 57), type IIIa (n = 5), type IIIb (n = 15), and type IV (n = 13) according to the Yakes classification system. Effectiveness of embolization was based on AVM devascularization on angiography: 100% (total), 90%-99% (near-total), 70%-90% (substantial), 30%-70% (partial), and 0%-30% (failure). Complications were graded according to the Society of Interventional Radiology classification.

RESULTS

In 69% of patients, 70%-100% devascularization was achieved. Total and near-total occlusion of the nidus were more often achieved in AVMs of types I and IIIa (both 100%) than in AVMs of types II, IIIb, and IV (56%, 67%, and 39%, respectively; P = .019). A total of 109 complications were identified: 101 minor (22.9%) and 8 major (1.8%). Major complications included wounds (n = 5), false aneurysm (n = 1), finger contracture (n = 1), and severe pain (n = 1) requiring therapy. The patient complication risk was significantly affected by the number of procedures (relative risk = 2.0; P < .001). Age, AVM location, and angioarchitecture type did not significantly affect complication risk.

CONCLUSIONS

AVM embolization resulted in 70%-100% devascularization in 69% of patients, with few major complications. This study indicates that the type of AVM angioarchitecture affects the number of procedures needed and the achievability of AVM devascularization.

Embolization of peripheral arteriovenous malformations and fistulas with precipitating hydrophobic injectable liquid (PHIL®)

PURPOSE

This paper reports on the preliminary experience of a single center in the embolization of peripheral AVMs and fistulas with precipitating hydrophobic injectable liquid (PHIL^®), focusing on technical aspects and short-term clinical outcomes.

MATERIALS AND METHODS

Seven males and five females were included in this study, mean age 42.16 years. For ten of them, it was the first embolization treatment; two had been previously treated with Onyx^® embolization. PHIL^® was injected with a transarterial approach without other embolics during the same procedure. Lesions were localized in small bowel (1), colon (1), head face (5), forefoot (1), uterus (1) and thorax (3); all were symptomatic. After 30-day clinical follow-up, a contrast-enhanced CT or MR was acquired at 3 months from intervention to detect eventual lesion residual.

RESULTS

After a single embolization procedure, complete technical success was obtained in 50%, while clinical improvement without additional therapies was appreciable in all patients. No technical failure occurred; in two cases, a small amount of PHIL^® proximally refluxed in nontarget vessels without clinical effects. No tattooing effects of superficial lesions neither artifacts at CT and cone-beam CT controls were evident.

CONCLUSIONS

PHIL^® seems to be a safe and effective liquid embolic agent for the treatment of peripheral AVMs and fistulas; although a direct comparison between PHIL and Onyx was not performed, PHIL might present the advantages of reduced artifacts at postprocedural CT scan and no need for shaking time preparation, but it is more expensive due to lower volume of product for each package and slightly less radiopaque at fluoroscopy.

Brain and Heart Crosstalk During Neurointerventional Procedures: The Role of the Trigeminocardiac Reflex: An Updated Systematic Review

The trigeminocardiac reflex is a well-described brainstem reflex that clinically manifests as bradycardia, hypotension, or apnea. This physiological phenomenon is extensively reported during open neurosurgical procedures, but very few data exist for trigeminocardiac reflex occurrence during neurointerventional procedures. This systematic review aims to provide aggregated information related to the trigeminocardiac reflex during neurointerventional procedures and to improve understanding of the various mechanisms that can incite this unique brain-heart crosstalk.

Uterine Arteriovenous Malformations

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.

Torrential bleeding of arteriovenous malformation in hand post-ethanol sclerotherapy: A case report

Embolization or sclerotherapy is considered as the first-line therapy for the management of arteriovenous malformations (AVM) and can be performed directly targeting the nidus. Ethanol is an effective embolic agent; however, some complications may arise. This paper illustrates a case of torrential bleeding following ethanol sclerotherapy in a patient with progressive hand arteriovenous malformations with a poor prognosis and was suggested to be amputated. Direct pressure, tourniquet appliance, and split-thickness skin graft procedure were performed to stop the bleeding successfully. No recurrence of bleeding was reported; and complete alleviation of pain was achieved.

Management challenges of a large upper extremity vascular malformation in a patient with capillary malformation-arteriovenous malformation syndrome

We describe a 17-year-old boy with capillary malformation-arteriovenous malformation syndrome and a massive vascular malformation of the right chest wall, shoulder, and upper arm. Persistent growth of the malformation caused cutaneous ulcerations and recurrent massive bleeding episodes. We proceeded with a modified shoulder disarticulation preceded by ligation of the subclavian artery and innominate vein by median sternotomy. After a staged debulking resection of the residual chest wall arteriovenous malformation with rotational transverse rectus abdominis myocutaneous flap coverage, the patient was discharged home safely. This report demonstrates that a multidisciplinary approach is critical for management of life-threatening complications in capillary malformation-arteriovenous malformation patients.

Popescu Technique Revisited: Review of the Literature and Case Series

Management of vascular malformations depends on the size, type, age of the patient, location, dissemination, and depth of penetration. Treatment options include propranolol, which reduces endothelial vessel proliferation, minimally invasive sclerotherapy to induce fibrosis, or surgery. In 1985, Valerian Popescu described a new approach to treatment consisting of intratumoral ligation by compartmentalization. This technique allows for high doses of the sclerosant agent to be delivered as systemic dissemination is restricted by a series of strangulating suture loops that divide the mass into segments. We describe the management and outcome of 2 patients who presented with vascular malformations in the orofacial region and were managed using a Popescu suturing technique. Vascular obliteration was achieved by a series of strangulating suture loops placed percutaneously throughout each lesion using a curved needle with a resorbable material (Vicryl; Ethicon, Somerville, NJ). The aim was to segment the vascular malformation into manageable sections for subsequent injection of a sclerosant. The compartmentalization also ensured that the sclerosant stayed within these compartments and was not washed out into the general circulation. Good esthetic outcomes were achieved in very visible areas such as the commissure and the vermillion border. In these areas, a surgical resection would have certainly caused a disruption of the esthetics of the lips and, in the second case, probably an alteration of function. Intratumoral ligation can be used safely to achieve control of vascular malformations with good esthetic outcomes.

Inline Balloon Occlusion-Assisted Delivery of Ethylene Vinyl Alcohol Copolymer for Peripheral Arterial Applications: A Multicenter Case Series

PURPOSE

To assess the feasibility, safety, and efficacy of balloon-assisted delivery of ethylene vinyl alcohol copolymer (EVOH) for a range of peripheral arterial applications.

MATERIALS AND METHODS

Six academic medical centers entered retrospective data on 46 consecutive patients (27 men, 19 women; ages, 11-94 y; mean age, 50.3 y) who underwent 60 balloon-assisted EVOH procedures. The cohort was restricted to procedures involving peripheral, nonneural arteries 1-5.5 mm in diameter. Clinical indications included a wide range of vascular pathologic conditions (most commonly arteriovenous malformations [n = 20], renal angiomyolipomas [n = 8], and acute hemorrhage [n = 9]) and targeted visceral and musculoskeletal peripheral arteries. Data collected included sex, age, clinical indication, arterial pathology, arteries embolized, type of occlusion balloon microcatheter, type and concentration of EVOH agent, effectiveness as an embolic backstop, vessels protected, adequacy of EVOH cast penetration, catheter extraction, nontarget embolization, and complications.

RESULTS

Balloon occlusion prevented EVOH reflux in 59 of 60 procedures (98.3%). Nontarget EVOH embolization occurred in 2 procedures (3.3%). Adequate EVOH cast penetration and complete filling of the target pathologic structure were seen in 57 of 60 procedures (95%). Balloon deflation and uneventful extraction occurred in all procedures; small EVOH fragments detached into target arteries in 2 cases. One major (1.7%) and 2 minor (3.3%) complications occurred.

CONCLUSIONS

Balloon-assisted EVOH embolization of peripheral arteries is feasible, safe, effective, and versatile. The primary advantage of balloon-assisted EVOH embolization is the ability to apply more injection pressure to advance the EVOH cast assertively into the pathologic structure(s).

Endovascular treatment of intracranial arteriovenous malformations using detachable-tip microcatheters and Onyx 18®

PURPOSE

To evaluate clinical and imaging features before embolization, data of embolization procedure and outcome in patients with ruptured or unruptured intracranial arteriovenous malformation (AVM) who were treated by endovascular embolization using detachable-tip microcatheters and Onyx 18^®.

MATERIAL AND METHODS

Forty-three patients treated with endovascular embolization using a detachable-tip microcatheter and Onyx18^® between January 2008 and April 2016 were evaluated. There were 27 men and 16 women with a mean age of 35.9±14.1years (range: 10-68years). Clinical and imaging features, embolization details and post-treatment findings were analyzed. Patients were divided into ruptured AVM and unruptured AVM groups. Death, complications and total embolization rates of each group were assessed.

RESULTS

Fifty-one embolization sessions were performed in 43 patients. Total embolization rate was 40% (17/43). There were significant relationships between AVM diameter and total embolization success and AVM diameter and complication rates. The degree of embolization was partial in all patients who had complications. Catheter retention and iatrogenic rupture were not observed in any procedure. No major neurologic deficit was seen in patients who had unruptured AVM and complications after treatment.

CONCLUSIONS

Our results show the efficacy of endovascular embolization of AVM using detachable-tip microcatheters and Onyx 18^®. A new AVM classification system based on AVM diameter for this embolization technique may be more predictive in terms of total embolization success and complication development.

Embolization of ovarian vein for pelvic congestion syndrome with ethylene vinyl alcohol copolymer (Onyx®)

PURPOSE

To evaluate the safety and efficacy of pelvic embolization using ethylene vinyl alcohol copolymer (Onyx^®) for pelvic congestion syndrome.

MATERIAL AND METHODS

Between March 2012 to September 2016, 17 women (mean age, 44.7± 12.2 (SD) years; range: 34-71years) presenting with pelvic congestion syndrome were evaluated for transvenous embolization with Onyx^®. Pelvic congestion syndrome was initially diagnosed by clinical examination and the results of transvaginal Doppler ultrasound and further confirmed by pelvic venography. Primary and secondary clinical efficacy was defined respectively by the resolution of the symptoms after embolization and at the end of the follow-up, irrespective to the number of embolization procedures.

RESULTS

Technical efficacy of embolization was 100% with no significant complications during and after embolization. After a mean follow-up time of 24.2 months (range: 6-69months) a primary and secondary clinical efficacy of 76.4% (13/17 women) and 94.1% (16/17 women) respectively were observed. Four women (23.5%) underwent a second embolization procedure with one woman requiring a third embolization procedure. These additional embolization procedures were associated with direct puncture of vulvar varices for sclerotherapy in two women. Five women (29%) had recurrent symptoms 21 months post-treatment (7-42months).

CONCLUSION

Pelvic embolization using ethylene vinyl alcohol copolymer (Onyx^®) has a favorable clinical success for pelvic congestion syndrome.